Citation Nr: 21008612 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 16-33 561 DATE: February 17, 2021 ORDER Entitlement to a 40 percent rating for sensory impairment right lower extremity is granted. Entitlement to a rating in excess of 10 percent for right upper extremity sensory deficit prior to November 18, 2019 and a rating in excess of 30 percent thereafter is denied. Entitlement to a total disability rating for individual unemployability (TDIU) due to service-connected disabilities prior to November 18, 2019 is granted. Entitlement to a TDIU due to service-connected disabilities from November 18, 2019, is dismissed as moot. FINDINGS OF FACT 1. The Veteran’s sensory impairment right lower extremity most nearly approximates moderately severe incomplete paralysis of the sciatic nerve. 2. The Veteran’s right upper extremity sensory deficit most nearly approximates mild incomplete paralysis prior to November 18, 2019 and was manifested by moderate severer incomplete paralysis thereafter. 3. Prior to November 18, 2019, the Veteran was unable to obtain and/or maintain substantially gainful employment due solely to her service-connected disabilities. 4. Entitlement to a TDIU due to service-connected disabilities from May 18, 2019, is dismissed as moot. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran’s favor, the criteria for an increased rating of 40 percent, but no higher, for the right lower extremity sensory impairment have been. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.159, 3.400, 4.1-4.7, 4.124a, Diagnostic Code 8520 (2020). 2. The criteria for entitlement to a rating in excess of 10 percent for right upper extremity sensory deficit prior to November 18, 2019 and a rating in excess of 30 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5103, 5107 (2012); 38 C.F.R. §§ 3.159, 3.400, 4.1-4.7, 4.124a, Diagnostic Code 8515 (2020). 3. The criteria for entitlement to a TDIU prior to November 18, 2019 have been met. 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.3, 4.15, 4.16 (2020). 4. The appeal for entitlement to TDIU since November 18, 2019 is moot, and the claim is dismissed. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 4.14, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2005 to May 2008. In May 2019, the Veteran and her husband testified at a video conference hearing (hearing) before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. This matter was previously remanded by the Board in June 2019 for additional development. It now returns for further appellate review. The Board of Veterans’ Appeals (Board) notes that a September 2020 rating decision granted the Veteran a 20 percent rating for right upper extremity sensory impairment effective November 18, 2019. However, the Veteran is presumed to seek the maximum available benefit for a disability. As such, this claim is still considered to be on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Rating 1. Entitlement to a rating in excess of 20 percent for sensory impairment right lower extremity The Veteran seeks a higher rating than the currently assigned 20 percent rating for her service-connected sensory impairment of her right lower extremity (RLE). See February 2015 Notice of Disagreement (NOD). Legal Criteria The Veteran’s RLE sensory impairment has been rated under Diagnostic Code (DC) 8599-8520. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27. The second diagnostic code provides further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id.; see Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006). Thus, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated by analogy. Accordingly, this Veteran’s RLE sensory impairment has been rated as paralysis of the sciatic nerve. DC 8520, which governs disabilities of the sciatic nerve, provides for a 20 percent disability rating where there is moderate incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a (diseases of the peripheral nerves), DC 8520. A 40 percent disability rating is assigned where there is moderately severe incomplete paralysis. A 60 percent disability rating is appropriate where there is severe incomplete paralysis with marked muscular atrophy. A maximum schedular 80 percent disability rating is assigned where the evidence shows complete paralysis of the sciatic nerve; with symptoms where the foot dangles and drops, no active movement possible of the muscles below the knee, flexion of knee weakened or lost. 38 C.F.R. § 4.124a, DC 8520. Regulations provide that ratings for peripheral neurological disorders are to be assigned based on the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Factual Background The Veteran is seeking a rating in excess of 20 percent for her RLE sensory disability. The Veteran’s 20 percent rating was continued in a February 2015 rating decision stemming from a May 2014 claim. Therefore, the rating period on appeal is from May 19, 2013, which is one year prior to the date of receipt of the claim. 38 C.F.R. § 3.400. By way of history, the Veteran was granted service connection for RLE sensory impairment effective February 2011 as secondary to service-connected multiple sclerosis. See November 2011 Rating Decision. In May 2013, the Veteran was provided a VA examination for multiple sclerosis (MS) for complaints of worsening gait and balance, numbness in legs, and fatigue. See May 2013 VA Multiple Sclerosis Disability Benefits Questionnaire (DBQ). The examiner noted that the Veteran had muscle weakness in lower extremities attributed to the Veteran’s MS. Id. The Veteran displayed full strength in her RLE including on hip extension, hip flexion, knee extension, and ankle plantar flexion and dorsiflexion. Id. The Veteran’s deep tendon reflexes (DTRs) in her right knee and ankles were 3+ which is consistent with increased reflexes without clonus or referred to as brisk reflexes. The sensory examination revealed decreased sensation in her right lower leg/ankle. However, there was no RLE muscle weakness noted. Id. She was noted to have abnormal gait and was unable to perform tandem gait. The Veteran uses a cane on a regular basis and occasionally uses a walker. Id. The Veteran reported lower extremity stiffness, spasticity, unsteadiness, weakness, and unsteady walking. See August 2013 VA Neurology in CAPRI received September 2014. However, she did not need assistance to walk and was noted to be independent. Id. Her prescribed medications included 300 milligrams (mg) of gabapentin three times a day. The neurologist noted that the Veteran was clinically stable. Id. On a follow up visit in April 2014, the Veteran endorsed similar symptoms but also noted that her RLE seemed weaker with intermittent “foot drop” but denied any major exacerbation. See April 2014 VA Neurology Note in CAPRI received September 2014. The neurologist noted that the gabapentin was helping with neuropathic pain, and that the Veteran remained independent. On physical examination, the Veteran demonstrated normal strength in arms and legs, and had brisk reflexes 3+ in her knees and ankles. Id. The Veteran was provided another VA examination for her service-connected MS in October 2014. See October 2014 VA Multiple Sclerosis DBQ. The examiner noted that the Veteran had muscle weakness in her upper and lower extremities that were attributable to MS. Id. The Veteran had abnormal gait which was described as guarded at times, and examiner noted she uses a walker when needed. The Veteran had reduced muscle strength (4 out of 5) upon testing of her right hip extension, hip flexion, and knee extension. The Veteran had increased DTRs in her right knee and ankle which were rated as 3+. Id. She displayed decreased sensation in her right thigh/knee and lower leg/ankle, and foot/toes. However, she did not have muscle atrophy due to MS. The examiner noted the Veteran had moderate RLE muscle weakness. Id. In August 2016, the Veteran demonstrated normal strength in arms and legs, and brisk reflexes 3+ in her knees and ankles. See August 2016 VA Neurology Note in CAPRI received December 2019. The Veteran reported ongoing chronic weakness, and lower extremity weakness, as well as unsteady gait. However, the neurologist noted that despite fluctuation of symptoms, the Veteran remained stable, did not need ambulatory aid, and that there was no exacerbation of symptoms in the past 6 months. Id. Similarly, in January 2017 the VA neurologist noted no exacerbation of symptoms since the last visit, and that the Veteran was stable. See January 2017 VA Neurology Note in CAPRI received December 2019. The Veteran’s August 2017 medication list included 300 mg of gabapentin three times per day. See August 2017 VA Medication List in CAPRI received December 2019. The Veteran testified during the May 2019 Board hearing that her symptoms worsened and that she experienced drop foot, which she described as needing to kick her knee out in order to walk, and inability to lift her leg up. See Hearing Transcript. She also stated that she needed a walker or support to walk. She further reported that her symptoms fluctuate and that she experiences flare-ups every day but was unable to state how long her flare-ups lasted. Id. The Veteran’s husband also testified that the Veteran’s leg starts dragging and that she gets exhausted from walking. He also stated that the Veteran experienced leg stiffness and was bedridden for two weeks a few years ago but was unable to identify when that occurred. Id. In June 2019, the Veteran’s MS symptoms were noted to be stable and she was able to do all of her activities of daily living. See June 2019 VA Neurology Note in CAPRI received July 2020. The Veteran displayed normal strength in her arms and legs. Id. There was no evidence of muscle atrophy. Her DTRs of her knees and ankles were noted to be 2+ which is considered normal. Id. Pursuant to the June 2019 Board remand, the Veteran was provided a VA examination in November 2019. See November 2019 VA Peripheral Nerves Conditions DBQ. The Veteran endorsed symptoms of daily numbness and tingling worse at the end of the day. Id. She treated her RLE sensory impairment with gabapentin. The Veteran reported no symptoms of constant pain or intermittent pain in her RLE. She characterized her symptoms of RLE paresthesias and/or dysesthesias and numbness as moderate. Her muscle strength testing on right knee extension, ankle plantar flexion, and ankle dorsiflexion revealed active movement against some resistance (4 out of 5). However, there was no evidence of muscle atrophy. The Veteran’s right knee and ankle DTRs were 3+ hyperactive without clonus. The Veteran had decreased sensation in her right upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. There was no evidence of trophic changes. Id. The examiner noted normal gait. The examiner found the Veteran had mild incomplete paralysis of the sciatic nerve. Id. There was no finding that the Veteran experienced foot dangles and drops or had no active movement of muscles below the knee, or flexion of knee weakened or lost. The examiner noted that the Veteran did not use any assistive devices. In a separate medical opinion, the November 2019 VA examiner stated that the Veteran’s RLE sensory deficit due to MS was mild, “however due to her MS (and the nature of MS) the demyelination of her nerves makes it difficult for her to maintain strength. Meaning her muscles fatigue easier than normal. Doing anything repetitive would exacerbate the weakness.” See November 2019 VA Medical Opinion DBQ. In July 2020, the Veteran was noted to have normal strength in her arms and legs. See July 2020 VA Neurology Note in CAPRI received July 2020. Analysis Upon review of the record, and giving the Veteran the benefit of the doubt, the Board finds that a 40 percent disability rating, for moderately severe incomplete paralysis is warranted for her RLE sensory impairment. The Board notes that the October 2014 and the November 2019 VA examiners found the Veteran’s RLE sensory impairment resulted in no more than moderate, incomplete paralysis. See October 2014 VA Multiple Sclerosis DBQ; see November 2019 VA Peripheral Nerves Conditions DBQ (noting moderate paresthesia and/or dysesthesias and numbness). The November 2019 VA examiner opined that the Veteran’s RLE sensory deficit was mild while noting that her service-connected MS “makes it difficult for her to maintain strength. Meaning that her muscle fatigue was easier than normal.” See November 2019 VA Medical Opinion DBQ. In granting the claim, the Board considered the Veteran’s credible lay statements regarding her symptoms including her testimony that she experienced drop foot, required a walker to ambulate, and has daily flare-ups of RLE symptoms. Since the neurological symptoms at issue are readily observable, the Veteran is competent to report on them. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). The available medical records concerning clinical treatment support the Veteran’s account. The Board notes both VA examination reports from 2014 and 2019 suggested a lesser degree of impairment due to RLE sensory impairment. However, the competent and credible reports from the Veteran and additional medical records indicating chronic weakness, well as unsteady gait are of at least equal probative weight. Thus, the Board resolves reasonable doubt in the Veteran’s favor and finds that the Veteran’s RLE sensory impairment more nearly approximates the criteria for moderately severe incomplete paralysis of sciatic nerve during the appeal period. 38 C.F.R. § 4.124a, DC 8520. The Veteran reported fluctuating symptoms of severe leg pain, weakness, sensory disturbance, foot drop episodes and imbalance. The clinical records show that the Veteran displayed decreased motor strength (4 out of 5) of the right leg, difficulty with ambulation, occasional foot drop and required an assistive device due to RLE weakness and pain. Additionally, the November 2019 VA examiner stated that the Veteran experienced easier muscle fatigue and was unable to maintain muscle strength. See November 2019 VA Medical Opinion DBQ. However, the Board does not find a rating in excess of 40 percent is warranted, because the medical and lay evidence does not more nearly approximate the severe criteria. Specifically, the rating criteria severe incomplete paralysis under DC 8520 requires marked muscle atrophy as an element and the evidence weighs against the presence of this symptom. 38 C.F.R. § 4.124a, DC 8520. Muscle atrophy and trophic changes for RLE have not been reported. The Board also notes the reports of foot drop, but points out that the clinical findings do not otherwise include findings, such as no active movement, that would more nearly approximate incomplete complete paralysis for her RLE. Id. Notably, the are no assertions of loss of use for RLE. In sum, the Board resolves reasonable doubt in the Veteran’s favor and finds that Veteran’s RLE more nearly approximates moderately severe incomplete paralysis. According, the Board grants a 40 percent rating for her service-connected RLE sensory impairment for the entire period on appeal. To the extent that any higher level of compensation is sought, the preponderance of the evidence is against the claim. Hence the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49; 38 U.S.C. § § 5107(b); 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to a rating in excess of 10 percent for right upper extremity sensory deficit prior to November 18, 2019 and a rating in excess of 20 percent thereafter The Veteran seeks a rating in excess of 10 percent prior to November 18, 2019 and a rating in excess of 20 percent for right upper extremity (RUE) sensory deficit thereafter. See NOD. Legal Criteria The Veteran’s RUE sensory deficit has been evaluated under DC 8599-8515. As noted above, hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27. The second diagnostic code provides further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. See Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006). Accordingly, this Veteran’s RUE sensory impairment has been rated as paralysis of the median nerve. Under DC 8515, mild incomplete paralysis of the major wrist warrants a 10 percent rating. 38 C.F.R. § 4.124a, DC 8515. A 30 percent rating is warranted for incomplete paralysis of the major median nerve that is moderate. A 40 percent rating is warranted for incomplete paralysis of the minor median nerve that is severe. Id. A 50 percent rating is warranted for incomplete paralysis of the major median nerve that is severe. Id. A 60 percent rating is warranted for complete paralysis of the minor median nerve that results in the hand inclined to the ulnar side, the index and middle fingers more extended than normal, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. See 38 C.F.R. § 4.124a, DC 8515. A 70 percent rating is warranted for complete paralysis of the major median nerve that results in the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. Id. The term “incomplete paralysis” used in reference to evaluation of peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied levels of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words “slight,” “moderate” and “severe” as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Factual Background The Veteran is seeking a rating in excess of 10 percent prior to November 18, 2019 and a rating in excess of 20 percent thereafter for her RUE sensory disability. The Veteran filed a claim for increase in May 2014. Therefore, the rating period on appeal is from May 19, 2013, which is one year prior to the date of receipt of the claim. 38 C.F.R. § 3.400. By way of history, the Veteran was granted service connection for RUE sensory impairment effective February 2011 due to associated service-connected MS. See November 2011 Rating Decision. In May 2013, the Veteran was provided a VA examination for multiple sclerosis (MS) for complaints of worsening gait and balance, numbness in legs, and fatigue. However, there were no specific complaints regarding her upper extremities. See May 2013 VA Multiple Sclerosis Disability Benefits Questionnaire (DBQ). The Veteran is right-hand dominant. The Veteran had normal muscle full strength in her RUE including on wrist flexion and extension, shoulder extension and flexion, and elbow flexion and extension. Id. She also had full grip strength (5 out of 5). The Veteran had normal reflexes on DTR testing of in her upper extremities 2+ except for decreased DTRs in her right brachioradialis noted to be 3+. The sensory examination of her right upper extremity was normal including in her inner/outer forearm and hand/fingers. Additionally, there was no RUE muscle weakness or atrophy noted. Id. In August 2013, the Veteran reported only lower extremity sensory impairment symptoms. See August 2013 VA Neurology in CAPRI received September 2014. On physical examination, the Veteran demonstrated normal strength in her arms and legs. Id. Similarly, the Veteran was noted to have normal strength in her arms in April 2014. See April 2014 VA Neurology Note in CAPRI received September 2014. The Veteran was provided another VA examination for her service-connected MS in October 2014. See October 2014 VA Multiple Sclerosis DBQ. The examiner noted that the Veteran had muscle weakness in her upper and lower extremities that were attributable to MS. Id. The Veteran had normal muscle strength (5 out of 5) in muscle strength testing on right shoulder extension and flexion, right elbow flexion and extension, and right wrist flexion and extension. She has displayed full muscle strength on right grip test. The Veteran’s had normal DTRs in her right upper extremities were noted to be 2+. Id. She displayed normal sensation in her right shoulders, inner/outer forearm, and hand/fingers. The Veteran did not have muscle atrophy due to MS. The examiner noted the Veteran had no RUE muscle weakness. Id. In August 2016, the Veteran demonstrated normal strength in her arms and legs. See August 2016 VA Neurology Note in CAPRI received December 2019. The VA neurologist noted that despite fluctuation of symptoms, the Veteran remained stable, did not need ambulatory aid, and that there was no exacerbation of symptoms in the past 6 months. Id. Similarly, in January 2017 the VA neurologist noted no exacerbation of symptoms since last visit, and that the Veteran was stable. See January 2017 VA Neurology Note in CAPRI received December 2019. The Veteran’s August 2017 medication list included 300 mg of gabapentin three times per day. See August 2017 VA Medication List in CAPRI received December 2019. The Veteran testified during the May 2019 Board hearing that her symptoms worsened and that she had difficulty opening bottles and writing due to her RUE sensory impairment. See Hearing Transcript. She further reported that her symptoms fluctuate and that she experiences flare-ups every day but was unable to state how long her flare-ups lasted. Id. In June 2019, the Veteran endorsed increased right-hand weakness, but she was noted to be able to do all of her ADLs including caring for her 14-month-old baby. See June 2019 VA Neurology Note in CAPRI received July 2020. The Veteran’s MS symptoms were noted to be stable and she was able to do all of her activities of daily living. Although some sensory paresthesia was noted, the Veteran displayed normal strength in her arms and legs. Id. There was no evidence of muscle atrophy. Pursuant to the June 2019 Board remand, the Veteran was provided a VA examination in November 2019. See November 2019 VA Peripheral Nerves Conditions Disability Benefits Questionnaire (DBQ). The Veteran endorsed symptoms of daily numbness and tingling worse at the end of the day. Id. She treated her RUE sensory impairment with gabapentin. The Veteran reported no symptoms of constant pain or intermittent pain due to her RUE sensory impairment. However, she endorsed moderate RUE paresthesias s and/or dysesthesias and moderate numbness. Her muscle strength testing of right elbow flexion and extension, right wrist flexion and extension, and right grip strength revealed active movement against some resistance (4 out of 5). However, there was no evidence of muscle atrophy. The Veteran’s s right biceps, triceps, and brachioradialis DTR were 3+ hyperactive without clonus. The Veteran had decreased sensation in her right shoulder area, inner/outer arm, and fingers. There was no evidence of trophic changes. Id. The Veteran Phalen’s sign and Tinel’s sign tests were negative. The examiner found the Veteran had mild incomplete paralysis of the median nerve. Id. In a separate medical opinion, the November 2019 VA examiner stated that the Veteran’s RUE sensory deficit due to MS was mild, “however due to her MS (and the nature of MS) the demyelination of her nerves made it difficult for her to maintain strength. Meaning her muscles fatigue easier than normal. Doing anything repetitive would exacerbate the weakness.” Id. In July 2020, the Veteran was noted to have normal strength in her arms and legs. See July 2020 VA Neurology Note in CAPRI received July 2020. Analysis a) Prior to November 18, 2019 Based on the record of evidence, the Board finds that the criteria for a rating in excess of 10 percent are not met. Prior to November 2019, the evidence is most consistent with mild impairment of the Veteran’s RUE. Notably, during the May 2013 VA examination, the Veteran had no upper extremity complaints and there were no reports of constant pain, intermittent pain, or paresthesias/ dysesthesias. See May 2013 VA Multiple Sclerosis DBQ. Additionally, the Veteran’s objective testing demonstrated full upper extremity strength, full grip strength, and normal sensory findings. Similarly, the October 2014 VA examination reflected no complaints of upper extremity pain or symptoms and was found to have normal upper extremity strength, reflexes, and grip strength. See October 2014 VA Multiple Sclerosis DBQ. In short, there is no evidence of more significant symptoms such as muscle atrophy, decreased reflexes, abnormal/limited movement of fingers/thumb, or loss of dexterity of her right hand. While the Veteran reported having increased symptoms, she did not demonstrate any abnormal reflexes, sensory, or muscle impairment during May 2013, October 2014 VA examinations. The Board is further persuaded that her RUE sensory impairment was mild as VA treatment records were mostly silent for complaints pertaining to her RUE. See August 2016 VA Neurology Note in CAPRI received December 2019(finding that there was no exacerbation of symptoms in the past 6 months.) See also January 2017 VA Neurology Note in CAPRI received December 2019 (no mention of upper extremity symptoms). Essentially, the Veteran’s statements are not only considered based on her testimony, but what she reported to her examiners for treatment of her disability. Although, she reported weakness in her RUE in June 2019, the VA neurologist determined that this was equivalent to the Veteran displaying full muscle strength in all of her extremities. See June 2019 VA Neurology Note in CAPRI received July 2020. In denying the claim for a rating in excess of 10 percent, the Board, as stated previously, has considered the Veteran’s statements that her RUE sensory impairment is worse, as well as her reports of paresthesias and functional limitations including inability to open jars and has difficulty writing. While she is competent to provide evidence regarding matters that can be perceived by the senses, she is not shown to be competent to render medical opinions regarding whether her symptoms meet the next higher rating criteria under VA regulations. Such competent evidence concerning the nature and extent of the RUE sensory impairment has been provided by the medical personnel who examined her during the current appeal. The medical findings (as provided in the examination reports and clinical records) directly address the criteria under which this disability is evaluated. Overall, the Veteran’s complaints are considered wholly sensory (pain and numbness) considering the normal motor strength and normal reflexes. The complaints and findings were considered by the examiners and determined to represent no more than mild incomplete paralysis. Given the symptoms are wholly sensory and were determined by examiners to be no more than mild in severity, the Board finds that the incomplete paralysis is no more than mild in severity and does not warrant a rating in excess of 10 percent for this period. Thus, as the criteria for a rating in excess of 10 percent for RUE sensory impairment prior to November 18, 2019 are not met, the claim is denied. b) From November 18, 2019 As an initial matter, the Board notes that the Veteran’s dominant hand is her right hand. See May 2013 Multiple Sclerosis DBQ. The Veteran was granted a 20 percent rating for RUE sensory impairment beginning November 18, 2019, based on the November 2019 VA examination report findings. However, the correct disability rating for moderate incomplete paralysis of the dominant hand is 30 percent. Accordingly, the Board finds that a 30 percent rating is warranted beginning November 18, 2019 for the Veteran’s RUE sensory impairment. During the November 2019 VA examination, she endorsed moderate RUE paresthesias s and/or dysesthesias and moderate numbness. See November 2019 VA Peripheral Nerves Conditions Disability Benefits Questionnaire (DBQ). The Veteran endorsed symptoms of daily numbness and tingling worse at the end of the day. Id. Notably, the Veteran displayed decreased muscle strength testing of right elbow flexion and extension, right wrist flexion and extension, and right grip strength revealed active movement against some resistance (4 out of 5). The Veteran’s s right biceps, triceps, and brachioradialis DTR were 3+ hyperactive without clonus. The Veteran also demonstrated decreased sensation in her right shoulder area, inner/outer arm, and fingers. Based on the November 2019 VA examination findings, the Board finds that most probative evidence of record showed worsening of the Veteran’s disability at that time was manifested by moderate incomplete paralysis of the median nerve. Accordingly, the Board finds that a 30 percent rating should be assigned for the Veteran’s RUE sensory impairment beginning November 18, 2019. The Board has also considered the Veteran’s contentions that her RUE sensory impairment is more disabling than the currently assigned rating. The Veteran is competent to report that her symptoms of pain and/or numbness. However, under the guidance provided in the Note accompanying 38 C.F.R. § 4.124a, that the Veteran’s statements by themselves do not provide the basis for a higher rating given the mostly normal examination findings. The Board considered the applicability of other DCs but finds no basis to assign a rating in excess of 30 percent for the Veteran’s RUE sensory impairment. The November 2019 VA examiner found mild incomplete paralysis of the Veteran’s right radial nerve, median nerve, and ulnar nerves. See November 2019 VA Peripheral Nerves DBQ. While mild incomplete paralysis of the ulnar and radial nerves were also present and mild incomplete paralysis was also noted for the median nerve, which would warrant separate ratings of 10 percent if these were the sole nerves involved, such a combination would constitute pyramiding, which is not allowed. See 38 C.F.R. § 4.124a, DC 8719 which indicates that combined nerve injuries should be rated by reference to the major involvement, which in this case is the radial nerve. Moreover, as there was no more than mild involvement of any of the reported nerves, no more than a 20 percent rating would be warranted for all radicular groups under 8511, 8512, or 8513. Although, the radial, median, and ulnar nerves comprise the lower radicular group, only the Veteran’s median nerve was found to be moderately severe while the ulnar and radial nerves were mild. As such, the Board does not find that the Veteran had moderate incomplete paralysis of the lower radicular group required for a 40 percent rating. Additionally, the evidence does not reflect severe incomplete paralysis of the median nerve. Severe incomplete paralysis involves more than sensory findings which are evidenced by atrophy, weakness, and diminished reflexes. Here, the evidence does not demonstrate that the Veteran experienced atrophy, weakness, and diminished reflexes of the frequency, severity, and duration consistent with severe incomplete paralysis. The Board also finds no evidence suggestive of complete paralysis. Indeed, the Veteran does not have a “griffin claw,” there is no evidence of atrophy or an inability to spread or fully extend the fingers or adduct the thumb, and weakened flexion of the wrist has not been shown. Additionally, the evidence of record does not show loss of muscle strength, absent reflexes, trophic changes or muscle atrophy in the Veteran’s RUE that is associated with more severe neurological impairment. Thus, based on the foregoing, the Board finds that the Veteran’s RUE most closely approximates the 30 percent disabling criteria for moderate incomplete paralysis of the median nerve. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Accordingly, the claim for a rating in excess of 30 percent is denied. 3. TDIU The Veteran contends that she is permanently unemployable due to her service-connected disabilities, and that a TDIU is warranted. See May 2014 VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability.  As an initial matter, the Board notes that the Veteran was granted a total schedular rating effective November 18, 2019 in the September 2020 Rating Decision. Notwithstanding the total schedular rating effective November 18, 2019, the TDIU claim remains in appellate status. The Board recognizes that the Veteran’s May 2014 VA Form 21-8940, is the date of claim for entitlement to a TDIU. See Harper v. Wilkie, 30 Vet. App. 356, 361-62 (2018) (holding that once the RO grants a TDIU that does not span the entire period on appeal, the issue of entitlement to a TDIU for an earlier period is still on appeal). Legal Criteria TDIU will be awarded when a veteran is unable to secure or follow a substantially gainful occupation because of a service-connected disability or disabilities. 38 C.F.R. § 4.16(a).  T o qualify for a TDIU on a schedular basis, the evidence must show (1) a single disability rated as 100 percent disabling; or (2) that the disabled person is unable to secure or follow a substantially gainful occupation because of her or her service-connected disabilities, with one disability ratable at 60 percent or more, or, for more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent or more.  Id.  The United States Court of Appeals for the Federal Circuit stated that the ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; that determination is for the adjudicator. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376, 381 (2013).  As such, the focus of the findings obtained on examination is not on whether the Veteran is unemployable due to her service-connected disabilities, but, rather the functional impairment caused solely by her service-connected disabilities in concert.  In Ray v. Wilkie, the United States Court of Appeals for Veterans Claims (Court) explained that substantially gainful employment contains economic and noneconomic components.  The economic component means “an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person,” while the noneconomic component requires consideration of a veteran’s ability to secure or follow that type of employment.  Ray v. Wilkie, 31 Vet. App. 58, 73 (2019).  The noneconomic factors include the Veteran’s: work history, education, skill, and training; the Veteran’s physical ability to perform work activities; and the Veteran’s mental ability to perform work activities required by the Veteran’s occupation.  Relevant Facts and Analysis Prior to November 18, 2019 In her May 2014 application, the Veteran reported she last worked in 2014 as an occasional bartender twice a month. See May 2014 VA Form 21-8940. She indicates that she completed one year of college education, and that her prior work experience included active service in the United States Army. Id. The Veteran’s Social Security income statement confirms that the Veteran earned $5,848 in 2014, $9,615 in 2015, $13,587 in 2016, and $4,897 in 2017. Her income for 2018 was not recorded. See Social Security Income Statement. Prior to November 18, 2019, the Veteran was service-connected for the following disabilities: acne and prurigo nodularis rated as noncompensable (0 percent); depressive disorder rated 50 percent disabling; multiple sclerosis rated 40 percent disabling; dysphagia rated as 30 percent disabling; sensory impairment of the RLE rated as 20 percent disabling effective February 2011, and 40 percent disabling May 2013; sensory impairment of the LLE rated as 20 percent disabling; RUE sensory impairment rated as 10 percent; sensory impairment of the LUE rated 10 percent disabling; bilateral knee patellofemoral syndrome each rated 10 percent disabling; bilateral optitis neuritis rated as 10 percent disabling; and speech impairment rated as 10 percent disabling. The Veteran’s combined disability rating is 90 percent prior to November 18, 2019. See September 2020 Rating Decision – Codesheet. During the May 2019 Board hearing, the Veteran’s husband testified that the Veteran was unable to work due to her MS complications including “her head pain and her ability not to be up and down.” See Hearing Transcript. Turning to the medical evidence, the October 2014 VA examiner opined that the Veteran should avoid strenuous activity and climbing stairs or ladders, avoid prolonged standing or walking, and be allowed to sit when needed due to her service-connected MS. See October 2014 VA Multiple Sclerosis DBQ. In November 2019, the VA examiner opined that the Veteran should work in sedentary positions only and should avoid prolonged standing, walking, lifting, bending, stooping, climbing stairs or ladders, and driving. See November 2019 VA Multiple Sclerosis DBQ. Regarding her psychiatric disability, a November 2019 VA examiner opined that the Veteran would have moderate difficulty functioning in an occupational environment and would have limited ability to carry out detailed instructions, sustain concentration, and perform activities on schedule. See November 2019 VA Medical Opinion DBQ. Regarding, the Veteran’s headaches, the November 2019 VA examiner opined that the Veteran would need to be allowed to rest and take medications for her headaches. See November 2019 VA Headaches DBQ. The November 2019 VA examiner also provided the following opinion regarding the functional impact of the Veteran’s service-connected disabilities “[d]ue to MS she cannot do any repetitive work lifting, walking, standing, climbing or squatting.) Due to the neuro[logical] presentation she should not drive or operate heavy machinery. Due to the MS and her symptoms (as well as headaches) she should avoid decision making or stressful situations. See November 2019 VA Medical Opinion DBQ. The Veteran reported that she worked as a bartender until 2017, and that she was scheduled to work three days a week due to her medical appointments. See October 2020 VA Form 21-4138. The Board finds that the Veteran meets the schedular requirements because she has a total schedular rating of 90 percent with at least one disability rated as 40 percent disabling including her service-connected MS and psychiatric disabilities. 38 C.F.R. § 4.16(a). As the Veteran meets the schedular requirements for TDIU, the remaining question is whether the Veteran’s service-connected disabilities render her unemployable.  As noted above, the Court defined the phrase “unable to secure and follow a substantially gainful occupation” to have two components: an economic component (an occupation earning more than marginal income); and a noneconomic component that considers such factors as the Veteran’s history, education, skill, training, physical ability, and mental ability. See Ray v. Wilkie, 31 Vet. App. at 73. Regarding, the economic component, the Board finds that the Veteran’s employment as a bartender was marginal employment. Marginal employment shall not be considered substantially gainful employment. For purposes of 38 C.F.R. § 4.16, marginal employment generally shall be deemed to exist when a veteran’s earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census (Census), as the poverty threshold for one person. However, even where earned annual income exceeds the poverty threshold, marginal employment may exist when the Veteran’s employment is limited to employment in a protected environment such as a family business, to self-employment, or to odd jobs. Here, the Veteran’s annual income did not exceed the poverty threshold in 2014, 2015, and 2016. See U.S. Department of Health and Human Services (HHS), Prior HHS Poverty Guidelines (https://aspe.hhs.gov/prior-hhs-poverty-guidelines-and-federal-register-references) (last visited February 10, 2021). Although, the Veteran’s 2016 income exceeded the poverty threshold for one person, the Board finds that her employment was marginal because it was in a protected environment as she worked limited hours and days. In this regard, the Veteran reported that she worked as a part-time bartender. She testified that she could not work an eight-hour day due to pain and fatigue. She further reported she was scheduled to work three-days a week due to her medical appointments. Thus, based on the foregoing, the Board finds that her employment was marginal. Accordingly, the economic component defined in Ray v. Wilkie has been met. Regarding, the noneconomic component, defined in Ray v. Wilkie, the evidence shows that the Veteran’s service-connected disabilities including MS, sensory impairment of her bilateral upper and lower extremities, and headaches, caused her to have difficulty due to pain, weakness and fatigue. For instance, the 2014 VA examiner noted the Veteran should avoid strenuous activity and climbing stairs or ladders, avoid prolonged standing or walking, and be allowed to sit when needed due to her service-connected MS. See October 2014 VA Multiple Sclerosis DBQ. Additionally, the November 2019 VA examiner stated that “[d]ue to MS she cannot do any repetitive work lifting, walking, standing, climbing or squatting.) Due to the neuro[logical] presentation she should not drive or operate heavy machinery.” See November 2019 VA Medical Opinion DBQ. The Veteran’s ability to perform the mental tasks necessary for substantial gainful employment was also impaired by the Veteran’s service-connected acquired psychiatric disability and her headaches. The November 2019 VA examiner stated that the Veteran’s “should avoid decision making or stressful situations[] due ot her headaches.” See November 2019 VA Medical Opinion DBQ. Regarding her psychiatric disability, a November 2019 VA examiner opined that the Veteran would have moderate difficulty functioning in an occupational environment and would have limited ability to care out detailed instructions, sustain concentration, and perform activities on schedule. See November 2019 VA Medical Opinion DBQ. Taken together the Veteran’s psychiatric and headache disability impair the Veteran’s ability to cope with the demands of a work environment. Based on the foregoing, the Board therefore finds that there is adequate medical evidence indicating that the Veteran’s service-connected disabilities in unison, and none individually, physically and mentally prevent her from being able to maintain any gainful employment. The Board finds that the Veteran’s lay statements are competent, credible and are of probative weight because they are consistent with the medical evidence of record. The evidentiary standard for TDIU opinions is not whether the average person would be precluded from substantially gainful employment, but whether the specific Veteran would be so precluded as a result of service-connected disabilities. Thus, when considering this specific Veteran’s disabilities in connection with her employability, the evidence of record establishes entitlement to TDIU. Therefore, affording the Veteran the benefit of the doubt, the claim for a TDIU is granted for the period prior to November 18, 2019. 38 U.S.C. § 5107(b). Beginning November 18, 2019 The Veteran was granted a total schedular rating effective November 18, 2019 in the September 2020 Rating Decision. When a total schedular disability rating is already in effect, a separate award of TDIU predicated on an additional service-connected disability may form the basis for an award of special monthly compensation (SMC). See Bradley v. Peake, 22 Vet. App. 280, 294-94 (2008). In other words, if the Veteran is found unemployable solely based on one of her service-connected disabilities, she may qualify for additional compensation in the form of SMC, which is available to veterans who have a single disability rated as total and a separate disability that amounts to 60 percent. 38 U.S.C. § 1114(s). The Board is obligated to assess all the veteran’s disabilities to see “whether any combination of the disabilities establishes entitlement” to SMC. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2010) (emphasis in original). The Veteran has a schedular 100 percent combined rating, throughout the pendency of the appeal period, a TDIU rating based on the combined effects of multiple service-connected disabilities cannot be assigned under the law. She has not alleged that she is unemployable solely due any one service-connected disability, nor does the medical evidence suggest such. Therefore, the issue of entitlement to TDIU is moot. See Bradley v. Peake, 22 Vet. App. 280, 293 (2008). Moreover, as a TDIU rating based upon multiple disabilities does not meet the single disability requirement for housebound benefits pursuant to 38 U.S.C. § 1114(s), any conclusion regarding TDIU based on multiple disabilities could not result in any benefit flowing to the Veteran. See Buie v. Shinseki, 24 Vet. App. 249-250. In short, because the Veteran already has a total rating based on the combined effects of her service-connected disabilities beginning November 18, 2019, there is no legal basis to award a TDIU based on the combined effect of those disabilities. 38 C.F.R. § 4.16. The claim for a TDIU based on combined disabilities beginning November 18, 2019 is therefore dismissed as moot. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Lilly, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.